Running on Empty

Audrey Weaver knew she needed to leave her hometown if she wanted to get better. She drove by the high school track where her mental illness began and felt sick at heart.

“I had a lot of bad associations with my house and with Bainbridge Island,” Weaver said. “I wanted to live on my own when I got out of treatment. I went home to grab my stuff and the next day I took a red-eye greyhound bus to Spokane.”

Spring 2017 track season: Weaver running the fourth leg of the 400 meter relay.

Weaver’s parents were sad to see her leave, but they wanted the best for their 18-year-old daughter. If that meant moving to Spokane, they would support her decision. After seeing Weaver struggle for nearly a year, all they could ask for was for her to be physically and mentally healthy again.

Within five months, Weaver had gone from being a top cross country runner at Bainbridge High School to a patient at a Seattle eating disorder treatment facility. She’d thought she needed to be thinner in order to run faster and took this mindset to the extreme. Between January and May 2017, Weaver developed an eating disorder that caused her to lose 20 pounds from her 118-pound frame and defer from the University of Oregon.

“I thought that if I started eating a little less, I would lose weight and be faster,” Weaver said. “It was like a game I played that very quickly spiraled into a huge issue.”

On a mission to get faster, many female runners end up “running on empty.” Some develop life-threatening eating disorders. In fact, 47% of elite female athletes in "lean" sports — such as distance running — have experienced eating disorders, as compared to 20% of athletes in non-leanness sports.

Although losing a few pounds may improve a runner’s performance initially, taking off too much weight can cause long-term health consequences, including low bone density and amenorrhea, the absence of menstruation due to an unhealthy body weight. These combined health effects result in a serious medical condition called relative energy deficiency in sport, or RED-S, an alarmingly common condition among female athletes.

The stories of these female athletes are all unique but familiar: Elite runner Mary Cain lost her period for three years and broke five bones. Collegiate runner Rachel Steil lost 20 pounds her senior track season of high school and didn’t have her period for over three years. Collegiate runner Emily Hubert had an irregular period for most of her athletic career, and became anemic in high school due to taking nearly six ibuprofens each day to mask the physical pain she was in. Olympic trials qualifier Adriana Piekarewicz lost her period for ten years and developed dangerously low bone density. All of these women were either told they would run faster if they lost weight, or they believed they would run faster if they lost weight.

“The problems within the running community are brushed under the rug all the time,” said Emily Hubert, a former cross country runner at Loyola Marymount University. “When I was in college, three girls ended up leaving the school because they had eating disorders. No one ever knew what happened until later on.”

Weaver’s negative body image started in the fall of her senior year of high school, after a stellar cross country season. Like many competitive runners, Weaver felt she needed to meet high expectations, especially as track season approached. A perfectionist, Weaver went the extra mile in all of her training sessions whether she was running hills or doing an ab workout.

“I felt like there was always this huge pressure to be perfect,” Weaver said. “People never really asked me how I was doing. People asked me where I was going to college and what I wanted to do with my life. My eating and running and the way I looked seemed like something I could control.”

Spring 2017 track season: Weaver running the third leg of the 200 meter relay.

Weaver didn’t stop until she saw changes in her physique and in her running performance. The two went hand-in-hand, she thought.

According to sport psychologist Riley Nickols, who specializes in treating athletes with eating disorders and is the Director of the Victory Program in St. Louis, Missouri, runners have a tendency to overestimate the effect of losing weight on their performance. “There is this notion of, if I can lose weight or change my body composition, then my performance will improve,” Nickols said.

Weaver remembers one day when she ate some cookies and felt an overwhelming sense that she couldn’t have them in her anymore. She threw up the cookies and later recalls writing in her journal, “I think I have an eating disorder.” But unfortunately, Weaver kept her thoughts locked in that journal until it was too late.

Adriana Piekarewicz, a serious runner since she was 12, dealt with malnutrition early in her running career. She attended a K-12 school in Florida and started competing with the high school team as a sixth grader.

Piekarewicz running the Tallahassee Palace Saloon 5k in 2017.

“I started really young and I was pretty clueless about running,” Piekarewicz said. “But I vividly remember the captain of my team saying that she was going on a diet of only eating fruit.”

It wasn’t long before eating breakfast became Piekarewicz’s greatest fear, and restrictive eating became a part of her life for the next 15 years. As a 7th grader, Piekarewicz ate about 100 to 200 calories in the morning and a light dinner.

“I had this technique where if my dad wasn’t in the kitchen then I would throw away my breakfast,” Piekarewicz said. “But if he was there and I had to eat it, then I wouldn't let myself eat anything else until dinner.”

According to sport psychologist Nickols, no one wakes up overnight with an eating disorder, and sometimes a person’s dieting behaviors may start out well-intended. “An athlete may just be mindful of what is going in their body from a nutritional standpoint,” Nickols said. “But over time, some develop rigid eating patterns that become more narrow and when they deviate from these rules, there are often feelings of guilt, shame or anxiety.”

Before Piekarewicz’s eating disorder spiraled out of control, her mother -- a nutritionist -- took charge of the problem and made sure her 12-year-old daughter ate. Piekarewicz says she was lucky she only had to see a therapist and not receive serious medical help at the time.

For the next couple of years, Piekarewicz ate well and set personal records as the top runner on her team. Then puberty hit and, like most women, she gained a few pounds.

“All of a sudden, I was the number two girl on my team and this middle school girl was beating me,” Piekarewicz said. “All of my junior year was pretty much that unhealthy relationship with food again.”

Burnt out from years of anxiety surrounding running, Piekarewicz had no desire to run track at Duke University as originally planned. She enjoyed the freedom of running on her own time and at her own pace without the pressure to appear a certain way.

Competitive runners face a dilemma: Losing weight without sacrificing long-term performance. A 2017 study found that the reduction of 5 or 10 percent of body fat may significantly improve performance time. The lighter the runner was, the faster the runner ran, the study found.

Another 2007 study found that people use the majority of their energy to support their body. Marathon runners, for example, are generally thinner than other athletes, such as sprinters. The two sets of runners differ in weight, muscle mass and speed. In a marathon, runners have to carry their entire body mass a distance of 26 miles, fighting gravity with each stride. The more force used to support a runner’s body weight, the more energy used. Put simply, the less a runner weighs, the less energy expended.

“The body is tremendously resilient,” Nickols said. “And what we see is that the performance of athletes with eating disorders doesn’t always immediately tank. In fact, performance for a lot of athletes we see momentarily increases.”

This phenomenon makes it even more challenging to identify and be aware that all is not well even when an athlete’s performance is good. For example, although some days were tough for Weaver and Piekarewicz, they were still performing well in the early stages of their eating disorders. In fact, many of Piekarewicz’s personal records are from 8th and 9th grade.

“It’s hard to argue with the runners who have eating disorders because they want to achieve something,” said Claudia Del Vecchio, a nutrition educator and certified wellness practitioner based in Los Angeles. “They are doing whatever they have to do to run better. But if they get to a point where their dieting behavior is getting out of hand, someone needs to pull them back and help them focus on their health.”

Del Vecchio understands the importance of leanness in running but wishes more female athletes, including runners, would understand the importance of fueling their bodies properly in order to prevent major health problems from developing.

Although Weaver and Piekarewicz were running relatively well in the early stages of their eating disorders, they both suffered from impaired physiological function, the part of an eating disorder that is not visible to the public. Weaver and Piekarewicz lost their periods and developed extremely low bone densities after years of “running on empty.”

Menstrual dysfunction and low bone density are two potential health consequences of having relative energy deficiency in sport, or RED-S. Athletes who fall in the category of RED-S usually have impairments of metabolic rate, menstrual function, bone health, immunity, and cardiovascular health, among other issues.

These RED-S impairments are caused by “low energy availability.” Simply put, Weaver’s extremely low body weight and dietary energy intake did not allow her body to properly function. Piekarewicz dealt with similar issues as Weaver, even though she suffered primarily with disordered eating rather than an eating disorder.

Not all runners meet the criteria for clinically diagnosed eating disorders. But the pressure to look a certain way or weigh a certain amount often results in distorted body image, which then leads to disordered eating.

Registered dietician Marci Anderson writes, “the most significant difference between an eating disorder and disordered eating is whether or not a person’s symptoms and experiences align with the criteria defined by the American Psychiatric Association.”

The association defines three main types of eating disorders including anorexia nervosa, bulimia nervosa and binge eating disorder. Each type causes severe life-altering disturbances in a person’s eating patterns, thoughts and emotions.

Athletes who struggle with disordered eating may have unhealthy thoughts about food and negative emotions towards their bodies, but they may never be clinically diagnosed with anorexia, bulimia, or binge eating disorder if, for example, their body weight is at a healthy average. That’s why the RED-S clinical assessment tool is so important. It allows doctors, psychologists, and athletes themselves to know when a body is at risk even if it appears healthy on the outside.

“Disordered eating is more so the behavioral aspect, what we observe within someone,” clinical psychologist Danielle Gonzalez said. “When you have someone who is participating in disordered eating, they might tell you, ‘A day before an event I might only have one meal…’ It may be disordered but not a diagnosis.”

Regardless of whether or not an athlete is clinically diagnosed with an eating disorder, sport psychologists urge anyone experiencing disordered eating habits that interfere with their daily lives to seek help before the problem escalates.

“They can train really hard but need to balance it out and then they will be able to train and run long term,” Del Vecchio said. “You won't be able to carry on that extremism forever. Nobody can maintain that level.”

When sport psychologist Lani Lawrence talks to female athletes, including distance runners, about their body image problems or eating disorders, her goal is to determine where the athlete’s thoughts stem from. Lawrence considers whether an athlete is losing weight because the athlete believes it will make her perform better or please a coach—or as a result of stress from school or relationships.

For Weaver, losing weight was not only about running faster. It was also a response to stress from school and expectations. Before her eating disorder started, Weaver was awarded MVP of her cross country team. Losing weight and running faster would show resilience and dedication to everyone she was eager to please, Weaver said.

For Piekarewicz, losing weight stemmed primarily from a mindset that she would be faster if she were smaller. But she also wanted to please her coach and be as fast as she was before puberty hit.

“Sometimes these ideas about ideal weight, body image, or performance come before they are even an athlete,” Lawrence said. “So first it involves understanding the athlete’s personal history with food and their body.”

Lawrence also asks her patients about what their coaches are telling them. “Goal-oriented coaching may contribute to disordered eating because it can mean win at all costs,” she said. A healthier style of coaching encourages looking at one’s own personal progress and ways to improve.

After months of overtraining and barely eating, Weaver’s body became frail and her muscles disappeared. She knew everybody was aware something was wrong. Two of her best friends told her they were concerned. Weaver’s coaches emailed her parents, who were confused and slightly angry. They had never told their daughter to lose weight and always made her feel beautiful, Weaver said.

“They were really mad out of love,” Weaver said. “They were like, ‘What did we do wrong?’.”

Instead of going to college, Weaver went to a residential eating disorder treatment program where her weight and meals were closely monitored. She was told not to run or exercise but secretly did so. The youngest patient there, 18-year-old Weaver yearned for freedom. She missed the days when running was a stress relief, rather than a means to lose weight.

Summer 2019: Weaver hiking at Mineral Ridge in Coeur d'Alene, Idaho

“When I first went to treatment I remember thinking I didn’t need to be there and that everyone else looked so much more sick than me,” Weaver said. “I had a very distorted body image of how I actually looked.”

In the midst of treatment, Weaver was diagnosed with bipolar disorder, which set her back physically and mentally. Weaver wanted to recover. She wanted to run again. But the medication and trauma were overbearing.

“I think sometimes there is a notion that eating disorders evolve because athletes just want to perform better,” Nickols said. “Initially that can be the catalyst of an eating disorder but after some point in time an eating disorder becomes so entrenched that it’s no longer about performance. It’s a psychiatric illness.”

Weaver says treatment was the hardest experience she has ever been through. She even ran away from the treatment facility one night, hoping to escape the sadness of being there. She put a bunch of clothes under her covers to make it look like she was still sleeping and quickly ran out the door. Luckily, one of the staff members was driving home from her night shift and saw Weaver. That was the night Weaver realized she had to change her behaviors in order to change her life.

“After that happened I realized I couldn’t just not care about anything,” Weaver said. “I thought, ‘How am I going to get anywhere in my life if I can’t even do treatment.'”

After graduating from high school, Piekarewicz stopped running competitively. She remembers being frustrated that her times were not improving as she got older, and feared her disordered eating would lead to larger issues if her performance was monitored.

“It’s the kind of thing when you see others succeeding and they are tiny, you think that that’s what you need to do to be fast,” Piekarewicz said. “And in running it works, but it works temporarily. You will be really good, really fast because, obviously, the lighter you are, the easier it is to run. But then you start getting injured.”

Piekarewicz knew she made the right decision to not run competitively in college. She was finally at a good place with her body and with food. But when she was a junior, a friend encouraged her to compete in a half marathon. That’s when the dangerous cycle of restrictive eating and dieting crept back up.

“Eating issues never fully go away,” Piekarewicz said. “Even if you are physically healthy and you are in a good place, there is always that lingering thing in the back of your mind if you’ve ever had an unhealthy relationship with food.”

From Piekarewicz’s junior year of college until just a few years ago, she has struggled to maintain a healthy body weight. As a result of years of restrictive dieting, Piekarewicz lost her period for almost ten years.

“I had such a messed-up mentality,” Piekarewicz said. “I thought not getting my period was a good thing because it meant that I was thin enough. I remember I got it randomly at one point and thought that meant I was fat. It is embarrassing to admit because it’s such a really disturbing way to think.”

In addition to losing her period, Piekarewicz developed dangerously low bone density by the time she was 25. Three times lower than what it should be for a woman her age, it was what you would expect for an 80-year-old.

Piekarewicz and her coach Donnie Cowart at the finish line of the Aviation Marathon in Warner Robins, Georgia on January 18, 2020. Piekarewicz's final race time was 2:44:55.

Piekarewicz, now 31 and a career coach at Wake Forest University in North Carolina, still struggles with disordered eating too. But what has changed in the past two years is her knowledge of the subject and her passion for it.

“Honestly, I just wish it wasn’t such a prevalent issue in the running community,” Piekarewicz said. “I have known one too many runners, including myself, with disordered eating habits. It doesn’t necessarily mean they are anorexic or bulimic, but I think restricting food is still an issue for a lot of runners and it needs to be addressed.”

Piekarewicz recently accomplished her lifelong goal of qualifying for the 2020 U.S. Olympic Marathon Trials. She says she has had the longest stretch of injury-free running in her life, and has been getting her best times in the longer distances than ever before. She says she finally understands the importance of fueling her body as a runner, and owes much of her success to overcoming the demon that once controlled her mindset about what it took to make it to the finish line.

“I think it’s so common and people really hesitate to talk about it,” Piekarewicz said. “I think the more that we talk about it and the more we share, the more likely it is that we can all overcome this together.”